Join a dedicated Care Transitions team as a compassionate Accredited Social Worker (BSW), providing vital patient and family advocacy alongside psychosocial support for individuals referred to the care transition program. Your role will focus on enhancing patient and family wellness, improving care outcomes, facilitating advance care planning, and ensuring access to post-acute physician services, hospital and outpatient care, and community resources.

Essential Functions

Systematically collect and analyze psychosocial data for patients, identifying needs and implementing appropriate interventions. Conduct home visits to perform comprehensive psychosocial assessments that consider social, cultural, emotional, and spiritual factors. Collaborate closely with care management staff and interdisciplinary teams to develop focused intervention plans tailored to patient needs, incorporating cultural values and beliefs related to illness, disability, and end-of-life care.

Work proactively to reduce hospital admissions and emergency visits by strategizing with healthcare teams. Address psychosocial and financial barriers that may affect patient progress or medical compliance. Respond ethically and promptly to suspected cases of violence, abuse, or neglect. Facilitate advance care planning, including discussions on healthcare proxies, living wills, advance directives, and power of attorney.

Stay informed on evolving care management trends, regulatory requirements, and payer policies. Utilize performance metrics to drive improvements in patient safety, satisfaction, and equitable care. Maintain accurate and timely documentation in compliance with privacy regulations. Foster positive relationships with patients, families, colleagues, physicians, and referral sources.

Minimum Knowledge and Skills

• Proficiency with MS Office and strong keyboarding skills.
• Effective communication and multitasking abilities.
• Expertise in social work assessment and counseling.
• Understanding of state and federal medical and financial support programs.

Required Behavioral Skills

• Integrity: Demonstrate honesty and ethical conduct, inspiring others to uphold organizational values.
• Compassion: Exhibit empathy and exceptional customer service in all interactions.
• Accountability: Take ownership of projects and adapt flexibly to changing priorities.
• Respect: Collaborate effectively with diverse populations, maintaining a positive service orientation.
• Excellence: Communicate persuasively, lead teams strategically and tactically, and drive process improvements.

Education and Experience

• Completion of an accredited Bachelor of Social Work (BSW) program is required.
• Preferred: Several years of experience in medical facilities, hospice, or home care settings.

Licensure and Certification

• Current licensure as a BSW in the relevant state.
• Healthcare Provider Basic Life Support (BLS) certification.

Embrace the opportunity to make a meaningful impact in a supportive environment serving the healthcare needs of the Midwest region. Competitive pay and a comprehensive benefits package are offered to support your professional journey.